23596 APPLICANT TO FILL IN INFORMATION WITHIN REO LINES- USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Bull 'ng Addrea • ..
23596
one:
rd 1.OlADYI `f?'x(� CITY OF CUPERTIN6BUILDINjDI
APPLICATION /PEBUILDING-FLFCTRICAI.PLUMBI G-MMCAL CATEGORY. CO �j
` QTY ELECTRIC PE FEE BUILDING PERMIT INFO
Address:
PERMIT IS VANCE ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
l am licensed under provisions of Chapter 9(eummen APPUANCFS SIDE L ]OB DESCRIPTION
tngwilh Sedlon 00)of Dlvlalon Sofj�e B slnessandPro mlonsCode,and my -
IlcenmIsInfu and
I.
CI P
Licen lam Llc#
Dat Gonbract t Tv�a
CHITECI'S DECLARATION 1-1
NO O I understand my plans shall be used as public record.. O ER 1 0 PS SQ.FT.FLOOR AREA g/SQ Fr.
r4 z�z Licensed Professimul N ECTRICAL
G�6 OWNER-BUILDER DECLARATION LCIR T/ `�•
2p, � I herebyafflrrn that am exempt from the Contrador's License Law for the
O following recon.(Section 7031.5,Bu.lness and Professions Code:Any city or LSCT7114P.M PO E
pNFW
� countywhkhrequimsapermltW.co tmd,alter,Impmve,de=lWh,orrepair
.9 anystmmmpeortoltsimuame,alsonqutr stheappliantforsuchpermitto O IOWERD CES file a signed statement that he is licensed pursuant to the provisions of the
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
�.�OJ sbn3of Ne Buslneae end Profeniam Code)orthathehexempttherefromand 'wN ELECTRIC VALUATION
the baste for the alleged exemption. Any violation of Section 7031.5 by any �R.� TCHFSN ES
Q applicant for a permit subjects the applicant to a civil penalty of not mre
uthen - !�• ' vC.
five hundred dollars($00). NEW RESID AL TR
�n nI,as owner of the property,or my employees with wages as their sole SQd'T STORIES TYPE CONSTRUCTION
compensation,willdo the work and thestrudure is not intended or offered for
O Ole(Sec.7094,Business and Professions Code:The Contradoes License Law ,
R does not apply toanowner ofpropertywho build.or improves therem,and
who doessuchwork himselforthrough his own employees,provided that such .00C.CROIfP b ES.UNITS
imprommenb are not intended oroffered for sale.IL however,the building or TOT
Improvements sold within oneyearofcompldlon,theowner Wilderwill have
thaIloods.of pmving that he did not build or improve for purpose ofsale.). QTy, PLUMBING PERMIT FEEFLOODZDNE ApN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contacrom to co�trudtMpmjed(Sec.7044,Businessand Profession Code:
The Contractor's LiMen Law does not apply to an owner of property who ALTER-DRAW kVENT-WATER(EA)
Wild.or Improves thereon and who contracts for such ptojeds with a mss'
co i.)
pursuant to the Contrsdor's License Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY
l lam exempt under See. B k P C for this reason
QI1TqlnF FEES
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y- N_
,./ WORKMAN COMPENSATION DECLARATION RECEIPT'#
�ydl hereby affirm that I have a mitiflate of consent mself-Insure,or FD(T'URES PER TRAP SCIi00L TAX Y_ N—
teofWorkera'Compev timlasunnaoracertifiedmpythereof(Sec. RECEIPT
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy# RECEIPT p
Com any GAS RA,SYSI'EM.OVER 4(EA) BUILDING DIVISID ES
Candied copy h heed with the cit. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID /ss
COMPENSATIONINSURANCE SRWER- STORM EA 200FT Date ecel t# v^"'
Qhissedion need not becomplded tithe permit R(Drone hundred dollars
($100)oify that
WATER HEATER W/VENT'/ELECTR ENERGY FEE Y N
I certlfytha[b the performance o(the work for which this permit Is Issued, —
I shall not employ any person in any manner so as to become subject to the
Workers'Compensation Laws of California.Date WATER SYSCAf/TREATING P
O Z Applicant
Z O NOTICE TO AI'PLICAM:H,aRer making tN.Cedi(late of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. ate Remi t#
should become cubed to the Workens'Compensation powulon of the Labor TOTAL:
WU) Code,your a,foonwhIl comply with such provisions orthis permit shall be B DI
deemed revoked. -
LU CONSTRUCTION LENDING AGENCY S S E
Iherebyaf(Irm that there is a construction lending agency forthe performE —r
O ante ofthe work for which this permit is Issued(Sec.3097,Civ.C.) T �
LI _ Lender'.Name - P LNG FEE la
Iy H Lender'.Addre.. QTY. MECHANICAL PERMIT FEE MECHANICAL E
O W Imddythatlhavereadthu.ppHatio..ad statethatlhe above information
1 ismmd.l agreeto comply with all city and county ordinances and nate laws PERSIUMSUANCE FEES PAID:
relating tobuliding mntmdlan,and hereby authortea representatives of this
)— Z city mentor upon the above-mentioned property for inspection purpose., ALTERORADDTOMWFL
V — (We o cove,Indemnify an d keep harmless the City of Cupertino Date Receipt#
agaln Wbllil ,judgrrents,coslsand expenseawhich may In anywayaceroe AIR HANDLING UNIT(TO 10,000 CFM) S TOTAL•
against sa3 ty In enre ofths,grant Ing at his permit
AIRHANDUNG UNIT(OVER Ig000CFM) CONSTRUCTION VAX
gnature of Ap sn/Conarador Date EXHAUST HOOD(W/DICT) CONSTRUCTION XPAID:
HAZARDOUS MATERIALS DISCLOSURE _
Willtheappllant or future building occopantstoreor handle hazardous HEATING UNIT CID 100,000 BTU) Date R el t#
material as defined by the Cupertino Municipal Code,Chapter 91Z and the
HwIth and Safetyode dion 25532(.)7 HEATING UNIT(OVFR IW OW BTU) T
171Vee No
Will the applla orfu building occupant use equipment or devices VENTILATION FAN(SINGLE RRSID) ,ISSUANCE DATE
which emit hazardous air contaminants as deflned by the Bay Area Air
Quality Manageme !Dist d7 BOILER-COMP OHP OR 100,000 BTU) A
❑Y a No a'7
I have read salthe a tde,Se tions 25505,255 3 and apter 25534.I of BOILER-COMP(OVIR21 W,000 BTU)
the California Health building
Code,Section 25505,have
a t and 25534.1 MAY 1
understandcity to If the nilly he
note ne,ulyhavea tenant that it is;my NEW RESIDENTIALMECH. SQ.FT. lass
responibilitymn the occupant of the requlremenb which must t��
encc a rtl(katE fOmpan Cir
.. yVrIf .
or out Ized agiV Date
TOTAL: - ISSUEDBY:�/r'
OFFICE COPY